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Member Profile Survey
*
1.
Contact Information
(Required.)
Name
Title
Organization
Email
Phone Number
2.
Does your organization have a Home Health Aide Training Program?
Yes
No
If no, where/how do you train your home health aides?
3.
Does your organization have a Personal Care Aide Training Program
Yes
No
If no, where/how do you train your personal care aides?
4.
Does your organization have a nurse preceptor program?
Yes
No
If yes, is your nurse preceptor a full-time position?
5.
Does your organization have a nurse residency program?
No
Yes
6.
Does your organization currently host nursing students for clinical rotations?
No
Yes. Please identify the nursing school.
7.
Is your organization unionized in the following staff categories?
Yes
No
Aides (Home Health Aides and/or Personal Care Aides)
Yes
No
If yes, what union?
Nurses and/or other professional staff
Yes
No
If yes, what union?
8.
What Electronic Health Record does your organization currently use?
9.
Does your organization have a designated contact for the following?
Please include name, title, and email or write N/A.
Advocacy
Emergency Preparedness
Billing
Media/PR
Education Trainer
10.
Does your organization have an outside Lobby Firm?
No
Yes. Please identify.
11.
Does your organization offer Telehealth services?
Telehealth is defined as
the use of electronic information and communication technologies to deliver health care to patients at a distance. NYS Medicaid covered services provided via telehealth include assessment, diagnosis, consultation, treatment, education, care management and/or self-management of a NYS Medicaid member. This definition includes audio-only services when audio-visual is unavailable, or a member chooses audio-only.
No
Yes
12.
Does your organization provide any of the following specialty programs?
Please select all that apply.
Telehealth
Wound Care Program
Home Infusion
Falls Prevention
Dementia/ Memory Care
Specialized Chronic Disease Management
Sepsis Prevention
Asthma Intervention
Caregiver Program
Maternal or Infant
Community Paramedicine
Care Transitions
Primary Care Program
Behavioral Health
Hospice and Palliative Care
Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Programs
None
Other. Please specify.
13.
Please identify your organizations primary patient population.
Select all that apply.
Low-income individuals and families
Youth and young adults
Young children, pregnant women, and new moms
Veterans
Persons with special needs
Older adults
Immigrants
Formerly incarcerated individuals
Other. Please specify.
14.
CHHAs, LHCSAs and FI members, from Schedule 19 of your most recently submitted Medicaid Cost Report (2022 reporting year) please provide the following:
Total Operating Revenue
Total Operating Expenses
15.
MLTC and PACE plan members, from Schedule B of your 4th Quarter 2023 Medicaid Managed Care Operating Report (MMCOR) please provide the following:
Total Operating Revenue
Toal Operating Expenses
16.
Hospice members, from your 2022 Hospice Cost & Utilization Report to DOH, please provide the following:
Total Revenue Received (HSR1 #19)
Total Program Expenditures (HSR1 #20F)
